Free UCS-3 - Florida

Employer Account Change Form

UCS-3 R. 08/07

Complete only the sections reflecting a change in the business.
Current legal entity name: SECTION 1: CONTACT INFORMATION Trade name (business, trade, or fictitious [d/b/a] name): Mailing address (street address, city state, ZIP): Business location (street address, city, state, ZIP): Contact (name): E-mail address: Change federal employer identification number to: SECTION 2: CORPORATION Phone: Fax: ­ ­ ­ ­ Unemployment tax account number: ­

­

(attach supporting IRS documentation)



Amendment to corporate charter (attach Articles of Amendment) Corporate name change to: Change in business activity (Indicate new business activity):



Officer change only



Stock sale only

SECTION 3: CEASED OPERATIONS Date of last payroll in Florida : ­ ­

SECTION 4: CHANGE IN BUSINESS STRUCTURE/LEGAL ENTITY STATUS (eg: sole proprietor to corporation, corporation to LLC, etc.) New legal entity name: (Check one) Sole proprietor Date change occurred: Partnership Corporation ­ ­ (Check one) Sole proprietor If LLC, classification for federal income tax purposes: Partnership Corporation SECTION 5: SOLD BUSINESS Date business sold: ­ ­ Was there any common ownership, management or control between Portion the two entities at the time the sale/change occurred? es No



All



Sold business to (legal entity name of new owner): Address (street address, city, state, ZIP): Phone: ­ ­

SECTION 6: LEASING EMPLOYEES Leasing employees:



es



No ­ ­

Are all employees (including corporate officers) leased? Leasing company's DBPR license number: Date leasing relationship began: ­ ­

es No

Leasing company unemployment tax account number: Leasing company federal employer identification number: SECTION 7: SIGN AND DATE

I certify that I am legally authorized to make these changes with respect to the account number shown above. Signature: Title: Date: Phone: ­ ­ ­ ­

Sign, date, and mail this Employer Account Change Form to:
Florida Department of Revenue PO Box 6510 Tallahassee FL 32314-6510

For information and forms: or fax to: 850-488-5833

www.myflorida.com/dor 800-482-8293